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Republic of the Philippines

JOSE RIZAL MEMORIAL STATE UNIVERSITY
The Premier University in Zamboanga Del Norte
BULLYING VIS-A-VIS ACADEMIC PERFORMANCE OF COLLEGE STUDENTS
QUESTIONNAIRE
Part I. Respondents Profile
Directions: Put a check () mark on the box which best describes you.

Name of Respondent (Optional):_____________________________________________
Age:
15 - 16 19 - 20
17 - 18 above 20
Gender:
Male Female
Monthly Income:
(35,000 and above) (15,000 - 20,000)
(25,000 - 30,000) (11,000 - 15,000)
(20,000 - 25,000) (10,000 and below)
Religion:
Roman Catholic Jehovahs Witness
Iglesiani Cristo Born Again
Others: (please specify: _______________________________)
College Enrolled at:
CED
CME
CBA
Final Grades of Subjects Enrolled at during the 1
st
Semester (SY 2013-2014): (only to
subjects applicable to you)
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Eng 11 Communication Arts/Skills

NATSCI 11 Physical Science
SOCSCI 11 General Psychology
MATH 11 College Algebra

Fil 11 SiningngKomunikasyon

PE 11 Physical Fitness/Gymnastics

SOC Sci 12 Phil Government and Constitution

Others, please specify and indicate the grade obtained

Gen. Average Grade ______________
Part II. Direction: Please put a check () mark to the corresponding column to a number written
in each indicator to bestexpress your opinion by using the scale below:
5 Always
4 Often
3 Sometimes
2 Rarely
1 Never

A. Sexual Bullying 5 4 3 2 1
1. I am intentionally touched by my (boy/girl) classmate in
my private part.

2. My (boy/girl) classmate playfully strokes his private part
at my back.

3. My schoolmate usually performs several mischiefs
regarding sexually oriented deeds inside the campus.

4. My seatmate maliciously held something behind my
back during classes.

5. One of my classmates posted a sexually offensive
blog on my page on one of the social networking
sites with my face on it.

B. Emotional Bullying
5 4 3 2 1
1. One of my classmates kept on spreading malicious
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rumors about me knowing that it was not true at all.
2. I feel that my classmates, schoolmates, friends are
avoiding me at any instance and they are keeping me
out of the group.

3. My classmates are making fun of me by saying hurtful
words at me.

4. I am being ignored by my colleagues at times purposely.
5. I can feel that my classmates and schoolmates are
treating me differently and pretended that I do not exist in
the group.

C. Physical Bullying
1. I am pushed, punched, shoved, kicked and tickled
by my classmate for no reason.

2. My classmate touches me inappropriately inside the
school campus such as in the lunchroom, bathroom,
hallway or in the playground.

3. My schoolmate usually performs several misdeeds
and even without limits.

4. My seatmate attacks me harshly without giving/
stating any reason of misconduct.

5. I am stroked with a deadly weapon, a pencil, a pen or
a ruler inside the classroom.

D. Verbal Bullying
1. I am insulted by my colleagues in front of the many
for no reason.

2. My classmate is directing foul language or vulgarity
which is embarrassing on my part.

3. I am always insulted by using derogatory terms and my
classmate is playing with my name.

4. My schoolmate is commenting negatively on my looks,
clothes, body, etc.

5. I experience personal abuse which include tormenting,
harassment, being laughed at and teased inappropriately.

D. Cyber Bullying
1. One of my classmates posted a picture of me using
other persons body in a nude on one of the websites.

2. My classmate e-mailed something that is very offensive
and harassing of my person.

3. Someone sent me an instant message and inappropriate
words on my yahoo messenger, facebook, etc.

4. Unknown person sent me an offensive text message via
www.magtxt.com .

5. Someone uses my facebook, e-mail address, yahoo
account, etc in making dreadful activities against
my will and without permission.

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